COLLEGE OF CHIROPRACTORS OF ONTARIO 2011 REGISTRATION RENEWAL by gjjur4356

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									                                                COLLEGE OF CHIROPRACTORS OF ONTARIO
                                                    2011 REGISTRATION RENEWAL
This is your notification that your completed renewal form and payment must be received at CCO by January 1, 2011, or your registration will be
suspended on or about March 1, 2011, and you will not be legally entitled to practise in Ontario.

The address below is the PRIMARY BUSINESS ADDRESS recorded in the official CCO Register. It will be used for all official correspondence,
printed in the CCO Directory, and posted on CCO’s website. Please verify accuracy and make necessary changes. If you do not have a business
address, your residence or other designated address will be used for all official correspondence and published. Please advise CCO if you would like
to receive your correspondence at your residential address instead. The information collected on this form is used only for the purpose of
regulating the profession and practice of chiropractic.

To:                                                                                                         Corrections:




             Tel.:
             Fax:
             E-mail:

Certificate Number:                                                             Current Status:

Eligible to Vote (Y/N):                                                         Electoral District:
                                                                                District Codes:       1 = Northern       2 = Eastern         3 = Central East
                                                                                                      4 = Central        5 = Central West    6 = Western

Residence Address:                                                                               Secondary Office Address(es) on Record (list all)


                       Tel:
                       Fax:

      Please check here if you do not want your facsimile or e-mail address printed in CCO’s directory.



PRACTICE INFORMATION
1.     Please select one class of certificate of registration that best describes your practice (refer to Policy P-052: Categories of Registration):
            General (Active)
            Inactive
            Retired
2.     If you do not provide direct patient care, are you employed in a capacity in which you make substantial use of your chiropractic knowledge,
       skills and judgment such as involvement in an educational, research, political, administrative or other position?
             YES If yes, please identify:
             NO
             N/A
3.     I primarily reside in Ontario:           YES           NO
4.     Language of choice: English / French
5.     Are you a dual registrant?            YES         NO
                                        If YES, name other profession(s) and date of registration:


6.     I use the following techniques in my practice (please list):


7.     I confirm that I learned every technique, technology, device or procedure I use in practice within the core                          YES          NO
       curriculum, post-graduate curriculum or continuing education division of an accredited chiropractic educational
       institution, or a Canadian or American university.
8.     If no, please identify the technique, technology, device or procedure, and outline your training:


9.     I confirm that I use acupuncture procedures in my practice as an adjunctive therapy and that I have read and comply                  YES          NO
       with standard of practice S-017: Acupuncture.
10.    I confirm that I have attended a CCO record keeping workshop.                 YES             NO
11.    I confirm that I am a shareholder in a health profession corporation.               YES          NO
12.    If YES, provide name, address and telephone number of every health profession corporation of which you are a shareholder:




X-RAY INFORMATION
1.     Do you have an x-ray facility in your office?              YES         NO
2.     If YES, is the x-ray facility:        Active (used within the last two years)              Dormant (not used within the last two years)
       If dormant, indicate the date the facility became dormant:
3.     Do you take your own x-rays?             YES          NO
4.     If NO, do you use a:             Chiropractic facility         Hospital facility           Medical facility
                                        Other – please specify:
5.     If you do not take your own x-rays, do you:        read the x-rays?                YES          NO
                                                          write the report?               YES          NO
                                                                           –2–


AUTHORIZATION TO WORK IN CANADA
You must be authorized to work in Canada by one of the following provisions. Please indicate which provision applies to you.
    Canadian citizen
    Permanent resident
    Engage in the practice of chiropractic profession under the Department of Citizenship and Immigration Act, 1994 (Canada)
    If no category applies, provide explanation:


PROFESSIONAL LIABILITY PROTECTION INFORMATION
Please indicate and confirm carrier and coverage:

COMMUNICATION FROM CCO
I would prefer to receive communications from CCO via email:                YES             NO
If yes, provide e-mail:

CHIROPRACTIC SPECIALTY INFORMATION ON RECORD
Please indicate if you have any of the following specialty designations and the date obtained:         Date:
     FCCO(C) – Fellow of the College of Chiropractic Orthopedists (Canada):
     FCCR(C) – Fellow of the Chiropractic College of Radiologists (Canada):
     FCCRS(C) – Fellow of the College of Chiropractic Rehabilitation Sciences (Canada):
     FCCS(C) – Fellow of the College of Chiropractic Sciences (Canada):
     FCCSS(C) – Fellow of the College of Chiropractic Sports Sciences (Canada):

INFRACTIONS SINCE REGISTRATION (if applicable)
Provide details of the following that have occurred since the date of your most recent renewal with CCO, including the description, date, name and
location of the court, and appeal status relating to the finding (use separate page). Check the appropriate box(es) below:
1.      Have you been found guilty of a criminal offence?                                                                           YES            NO
2.      Have you been found guilty of a non-criminal offence (e.g., a provincial offence) which may be relevant to your             YES            NO
        suitability to practise?
3.      Has there been a finding of professional misconduct, incompetence or incapacity in relation to another health               YES            NO
        profession in Ontario or in any other jurisdiction in which you are registered or licensed to practise chiropractic
        or another health profession?
4.      Is there currently a proceeding for professional misconduct, incompetence or incapacity in relation to another              YES            NO
        health profession in Ontario or in any other jurisdiction in which you are registered or licensed to practise
        chiropractic or another health profession?
5.      Has there been a finding of professional negligence or malpractice against you, which has not been reversed on              YES            NO
        appeal?

ACKNOWLEDGEMENT OF COMPETENCE AND GOOD CHARACTER
(if you answer NO to either question, please provide a written explanation on a separate paper)
1.      I confirm that I am mentally competent to practise chiropractic.                                                            YES            NO
2.      I confirm that I will practise chiropractic with professionalism, decency, integrity, honesty and in accordance             YES            NO
        with the law.



                                                  REGISTRATION PAYMENT INFORMATION
Please make cheque(s) payable to College of Chiropractors of Ontario. Credit card payments not accepted. Registration renewals must be received by
January 1, 2011, or be subject to a late payment fee.

General (Active) Certificate Members
     enclosed is my full fee payment of $950, payable January 1, 2011
     enclosed are my two payments of $500 each, payable January 1, 2011, and June 1, 2011
     $100 late payment fee (if applicable)

Inactive Certificate Members                                                      Retired Certificate Members
     enclosed is my full fee payment of $475, payable January 1, 2011                    enclosed is my full fee payment of $100, payable January 1, 2011
     $20 late payment fee (if applicable)                                                $20 late payment fee (if applicable)

CCEB Examiner
I served as a CCEB examiner for the year 2010:             1 sitting        2 sittings

Please note: if you served as a CCEB examiner for one sitting, you must pay half of the General registration fee. If you served as a CCEB examiner
for two sittings, you are exempt from paying the full General registration fee.
Payment enclosed:            $475            Fee exempt

NOTE: This renewal form must be completed in full, signed and dated before it can be processed. Incomplete forms will not be considered to
have met the due date and will be returned to the member, which may result in the member being charged a late fee. Cheques that are
returned N.S.F. or are non-negotiable (i.e., misdated, not signed or otherwise miswritten) will also be returned to the member. A $50 charge
will be applied to all N.S.F. cheques in addition to the late fee, if applicable.

I declare the information as recorded on this registration form to be true and complete and undertake to advise CCO immediately if there is any
change in the information provided on this form.

Date:                                                            Signature:

								
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